How to manage hemoptysis in a patient with a history of Pulmonary Tuberculosis (PTB) and a 1-month history of chills?

Management of Hemoptysis in a Patient with History of Pulmonary Tuberculosis and 1-Month History of Chills

Immediately assess hemodynamic stability and severity of bleeding, obtain CT chest with IV contrast to identify the bleeding source and evaluate for TB reactivation or complications, initiate empiric anti-tuberculosis therapy given the history of PTB and systemic symptoms, and prepare for bronchial artery embolization if massive hemoptysis develops. 1, 2

Initial Assessment and Severity Stratification

Determine if this is massive hemoptysis (bleeding placing the patient at high risk for asphyxiation or exsanguination) versus non-massive hemoptysis, as the rate of bleeding correlates more closely with mortality than total volume. 1, 2 The presence of chills for 1 month suggests either TB reactivation, superimposed infection, or chronic pulmonary aspergillosis complicating old TB cavities. 3, 4

For Clinically Unstable Patients with Massive Hemoptysis:

• Proceed directly to bronchial artery embolization (BAE) without delay, as delaying BAE significantly increases mortality. 1, 2, 5
• Intubate immediately with a single-lumen cuffed endotracheal tube to allow bronchoscopic suctioning and clot removal. 2, 5
• Do NOT perform bronchoscopy before BAE in unstable patients—this wastes valuable time and increases mortality. 5
• BAE has immediate success rates of 73-99% in controlling bleeding, with tuberculosis being one of the most common etiologies in Asian studies showing 87-94% immediate success rates. 6, 1

For Clinically Stable Patients:

• Obtain chest radiograph initially to assess extent of disease—two or more opacified lung quadrants correlate with increased mortality risk. 1, 2
• CT chest with IV contrast is the preferred diagnostic test to identify the cause and location of bleeding, with diagnostic accuracy of 80-90% and superior to bronchoscopy (77% vs 8% diagnostic yield). 1, 2
• CT angiography has become the standard of care for arterial planning if BAE is being considered. 2

Specific Considerations for Post-TB Hemoptysis

Tuberculosis sequelae are among the most common causes of hemoptysis, particularly in patients with cavitary disease, bronchiectasis, or aspergillomas developing in old TB cavities. 6, 4 The 1-month history of chills raises three critical possibilities:

1. TB Reactivation:

• Initiate empiric anti-tuberculosis therapy immediately while awaiting diagnostic confirmation, as active TB is a common cause of hemoptysis in patients with prior PTB. 7, 8, 9, 10
• Standard regimen: Isoniazid 5 mg/kg (up to 300 mg daily), rifampin, pyrazinamide, and ethambutol for 2 months, followed by isoniazid and rifampin for 4-7 months. 7, 8, 9
• Obtain sputum cultures before starting therapy to confirm susceptibility and monitor for drug resistance. 7, 8

2. Chronic Pulmonary Aspergillosis:

• Aspergillomas have the highest recurrence rate of hemoptysis (55%) after BAE, making definitive surgical treatment necessary following initial BAE for acute massive hemoptysis. 2, 3
• Tuberculosis is the most common underlying disease for aspergilloma formation in preexisting cavities. 3, 4
• If aspergilloma is identified on CT, antifungal therapy alone is often inadequate—surgical resection or BAE with close follow-up is required. 3, 4

3. Pulmonary Artery Pseudoaneurysm:

• Pseudoaneurysms can develop from erosion of bronchial or pulmonary arteries due to cavitary infiltration in TB patients. 6, 11
• Over 90% of massive hemoptysis originates from systemic arterial supply, but 8-10 of 76 patients in one series had pulmonary arterial bleeding requiring pulmonary artery embolization in addition to BAE. 6, 11

Medical Management

Immediate Interventions:

• Administer antibiotics for at least mild hemoptysis, as bleeding may represent a pulmonary exacerbation or superimposed bacterial infection. 1
• Stop NSAIDs immediately as they impair platelet function and worsen bleeding. 1, 5
• Discontinue anticoagulants during active hemoptysis; resume only after 12-24 hours of complete resolution. 5
• Establish high-flow oxygen and large-bore IV access (ideally 8-Fr central line). 2

Bronchoscopic Management:

• Bronchoscopy provides diagnostic information on anatomic site, side of bleeding, and severity with 70-80% diagnostic yield. 1
• Bronchoscopic-guided topical hemostatic tamponade therapy using oxidized regenerated cellulose mesh immediately arrested hemoptysis in 98% of patients. 1
• Use bronchoscopy for airway clearance, clot removal, and potential tamponade with iced saline instillation or bronchial blockade balloons. 2

Post-Intervention Management and Follow-Up

• Admit all patients to intensive care for monitoring of coagulation parameters, hemoglobin, blood gases, and ongoing bleeding. 2
• Recurrence of bleeding occurs in 10-55% of cases after BAE, with higher rates in TB patients, aspergillomas, malignancy, and sarcoidosis. 1, 2
• Recurrence within 3 months is often due to incomplete embolization; after 3 months, it's typically due to vascular collateralization or recanalization. 2
• Recent studies show no increased morbidity or mortality for repeat BAE interventions. 2
• Continue anti-tuberculosis therapy for the full duration (typically 6-9 months) even after hemoptysis resolves, as premature discontinuation increases relapse rates. 7, 8

Common Pitfalls to Avoid

• Do not delay BAE to perform bronchoscopy first in unstable patients—this significantly increases mortality. 1, 2, 5
• Do not use double-lumen endotracheal tubes as initial airway management—single-lumen tubes allow better suctioning and clot removal. 5
• Do not assume old TB is inactive in a patient with new systemic symptoms like chills—always evaluate for reactivation. 7, 10
• Do not rely on chest radiograph alone for diagnosis—CT with contrast is essential for identifying bleeding source and complications. 1, 2
• Do not continue NSAIDs or anticoagulants during active hemoptysis. 1, 5